Varicoceles are a relatively common problem that can hurt a man's fertility. The good news is that this is a fairly simple problem to fix. In my practice I have treated hundreds of men for this condition. Although each case is unique, I have found that my patients often have similar questions and concerns. I've written this guide help you understand what a varicocele is and how it can be treated successfully. The more you know, the less anxious you'll be about the procedure and the more control you'll feel in your post-operative recovery.

This guide is designed in a simple question and answer format to address particular concerns, as well as to expand on other issues that also need to be understood before proceeding with varicocele repair. If you have any further questions or would like a brochure or a consultation, please contact my office.

Harry Fisch, MD
Professor of Clinical Urology
Columbia University Medical Center
of New York Presbyterian Hospital

Table of Contents

1. What is a varicocele?

2. How does a varicocele hurt my fertility?

3. How common are varicoceles?

4. How are varicoceles diagnosed?

5. How can a varicocele be fixed?

6. Do I need any special tests before surgery?

7. What type of anesthesia is used?

8. What should I expect after surgery?

9. How soon can I have sex after surgery?

10. When will I know if the surgery was successful?

11. What are my options if the repair doesn't solve the problem?

12. A Varicocele Case History (excerpt from "The Male Biological Clock")

13. Scientific articles on Varicoceles published by Dr. Fisch

1. What is a varicocele?
A varicocele (pronounced VAR-uh-ko-seal) is a bundle of enlarged veins in a man's scrotum, which is the sac that holds the two testicles. The veins are usually visible as lumps on the scrotum and feel like a bag of worms when massaged gently. The veins become enlarged because some of the tiny valves inside the veins don't close properly. The valves normally prevent blood from draining backwards. When the valves fail, blood pools in the veins, causing them to swell. Many men don't realize they have a varicocele because the veins typically don't hurt and don't change the feeling of orgasm or ejaculation.

2. How does a varicocele hurt my fertility?
Sperm are made in the testicles, which hang in the scrotum away from the body. This design is required because testicles need to be slightly cooler than normal body temperature to make sperm. Anything that warms the testicles will hurt sperm production. This is what a varicocele does. The extra blood pooling in the enlarged veins warms the nearby testicle unnaturally and cuts sperm production.

3. How common are varicoceles?
About 20% of the male population have some kind of varicocele. Varicoceles are probably the result of very subtle genetic effects which, a present, remain unknown. Sometimes varicoceles begin to form in the teen years, which is cause for concern. Untreated adolescent varicoceles can result in under-sized testicles, lower semen volumes, lower sperm counts, and more misshapen sperm.
But varicoceles can happen at any age…and in general, the older you are the more likely you are to have a varicocele. Unfortunately, many doctors still don't recognize the role that varicoceles play in male infertility and may minimize the importance of having a varicocele corrected surgically.

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4. How are varicoceles diagnosed?
Since they seldom cause any pain or discomfort, most varicoceles are discovered during routine physical exams, or exams associated with an infertility work-up. Physicians typically diagnose varicoceles by asking the man to stand up, take a deep breath, and bear down while the physician feels the scrotum above the testicle. If a varicocele is suspected, a physician may order a scrotal ultrasound test, but this is fairly uncommon because the classic "bag of worms" feel of a varicocele is so distinctive.

5. How can a varicocele be fixed?
Varicocele repair surgery is relatively simple. The goal is to locate the distended veins and tie them off or block them to prevent blood from pooling. There are three main surgical techniques used to correct a varicocele and one non-surgical technique. Which method is best depends on the particulars of a man's anatomy, the nature and location of the varicocele, whether previous surgery has been performed, and other factors such as surgeon preference and/or amount of experience.
Most commonly, surgery is performed through a single incision in the lower abdomen on the affected by the varicocele. Some procedures use smaller incisions, which avoids cutting as much muscle tissue and speeds recovery. (I have been perfecting surgical techniques for varicocele repair and have published articles such as"A Novel Surgical Approach to Subinguinal Varicocelectomy: Artery and Lymphatic Isolation Technique, Urology International, September, 2003" describing the improved procedures.) As with most surgery, practice makes perfect, so be sure to choose a surgeon with demonstrated expertise in these techniques. Complications from varicocele repair are rare, but include the persistence or recurrence of the varicocele, formation of a fluid-filled space called a hydrocele, and injury to the testicular artery.

The non-surgical procedure for varicocele repair is called percutaneous embolization and it is much less commonly used than surgery. In this procedure a special tube is inserted into a vein in either the groin or neck and guided to the varicocele. Once in position, a tiny coil or balloon is released that blocks the veins. Percutaneous embolization usually takes several hours to complete.

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6. Do I need any special tests before surgery?
No special preoperative tests are needed before a varicocele repair other than the standard lab tests required by some hospitals, ambulatory surgery facilities or anesthesiologists. For men more than 40 years old, an EKG is usually required.

7. What type of anesthesia is used?
Varicocele repair may be performed with local, regional, or general anesthesia, depending on the preference of surgeon and patient. General anesthesia is commonly used because it affords maximum patient comfort during the surgery.

8. What should I expect after surgery?
Varicocele surgery is usually done on an outpatient basis, and recovery us usually rapid. Pain is usually mild. Swelling around incisions usually goes away after several days, and discoloration of the scrotum will resolve in a week or so. You shouldn't lift anything heavy or exercise strenuously for two weeks, although office work can typically be done one to two days after surgery.

9. How soon can I have sex after surgery?
It is generally best to wait three weeks after the surgery before resuming any type of sexual activity.

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10. When will I know if the surgery was successful?
It takes about three months for sperm cells to be created and matured. A follow-up semen analysis is thus usually obtained three to four months after the surgery. The physician will evaluate the number and health of the sperm and compare this with a sample taken before the procedure. Improvement is often seen within six months, but may not be observed until one year after the surgery. Semen quality is improved in about 60 percent of infertile men undergoing correction of a varicocele.

11. What are my options if the repair doesn't solve the problem?
If a man's semen quality does not improve after varicocele repair, and if other potential sources of infertility are ruled out (such as an infection in the reproductive tract) several options remain to allow the man to father children. On option involves taking healthy sperm from a man's ejaculate and using this for in-vitro fertilization (IVF). If a man has no sperm in his ejaculate sperm may still be obtained through a minor surgical procedure (sperm retrieval) which extracts sperm directly from the testicles and/or epididymis. For more information about these techniques, see the "Help for Patients" portion of my website.

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12. A Varicocele Case History (excerpt from "The Male Biological Clock")
The following case from my practice illustrates some of the points about varicoceles I've been discussing in this Guide.
Michael and Cheryl had been married for two years, and decided to start trying to have a child on a cruise to Bermuda. After six months without a pregnancy, they began to get worried, but figured it might have something to do with the fact that they both were nearing 40.

"We both work incredible hours and have very high-stress jobs," Cheryl says. "We were buying a house, and we thought those were all contributing factors. We just never slowed down."
Several months later Michael went to a local urologist, who did a basic semen analysis and physical exam.

"He said my sperm count was on the low side of normal and that he saw a small varicocele but that it wasn't anything to worry about," Michael says.

Meanwhile Cheryl had a complete fertility workup including a surgical examination of her ovaries. No abnormality was found.

When Michael and Cheryl finally came to see me, they were frustrated by the lack of answers and by the reluctance on the part of their doctors to consider seriously what I felt were two important findings: I believed the varicocele was much more severe than Michael's doctor did, and when I did a semen culture I also found signs of a urinary tract infection. I recommended a course of antibiotics and that the varicocele be repaired as quickly as possible.

When I operated on Michael I found a set of very large veins-much larger than I had suspected. The surgery went smoothly. Because it takes three months for new sperm to form and mature, I waited that long to do another sperm analysis.

"It was Halloween and we were walking around with our nephews and nieces, out on the sidewalk, and Dr. Fisch called me on my cell phone with my test results," Michael says. "It was kind of a funny place to be talking about my sperm count you know? But he said everything looked great, the sperm looked good and the infection was gone. I turned to Cheryl and said, 'Hon, we can go for it.' I was elated."

Michael and Cheryl believe they conceived that Christmas Eve. The following September, after a normal pregnancy, their son Colin was born weighing 8.9 pounds.

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13. Scientific articles on Varicoceles published by Dr. Fisch
A Novel Surgical Approach to Subinguinal Varicocelectomy: Artery and Lymphatic Isolation Technique, Urology International, September, 2003

Adolescent Varicocele, AUA Update, October 2004

The surety of surgical repair of varicocele, Contemporary Urology, 1991

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